VITAL SIGNS

T= 37
50 y/o MALE
HR= 106
LOC RR=26
BP=190/100
Multiple fractures severe head injury s/c to fall

GCS =9

The purpose of the baseline information is to assess the effect of the program and to
compare what happens before and after the program has been implemented. Without
baseline data, it's difficult to estimate any changes or to demonstrate progress, so it's best to
capture baseline whenever possible.

02 SAT = 92

VITAL SIGNS VITAL SIGNS

T= 37.2 T= 36.5
HR= 108 HR= 100
RR=24 RR=24
BP=190/100 BP=176/90

VITAL SIGNS VITAL SIGNS

T= 37 T= 36.4
HR= 104 HR= 106
RR=25 RR=27
BP=185/90 BP=172/90

VITAL SIGNS VITAL SIGNS

T= 36.9 T= 36.4
HR= 103 HR= 106
RR=24 RR=22
BP=184/90 BP=170/90
VITAL SIGNS
VITAL SIGNS
T= 36.8 T= 36.2
HR= 102 HR= 106
RR=26 RR=26
BP=180/90 BP=160/100
The Glasgow Coma Scale (GCS) is the most common scoring system used to
describe the level of consciousness in a person following a traumatic brain injury.
Basically, it is used to help gauge the severity of an acute brain injury. 

GCS 8 or less. Moderate: GCS 9-12. Mild: GCS 13-15.

Mild brain injuries can result in temporary or permanent neurological

symptoms and neuroimaging tests such as CT scan or MRI  may or may not
show evidence of any damage.

Moderate and severe brain injuries often result in long-term impairments

in cognition (thinking skills), physical skills,
and/or emotional/behavioral  functioning.
 Eye opening Movement Verbal

 Obeys commands
4– 5 – Oriented
Spontaneous
3 – To speech 5 – Localizes to pain 4 – Confused
2 – To pain 4 – Withdraws from pain
3 – Inappropriate words

1 – None 2 – Incomprehensible sounds

3 – Abnormal flexion to pain
1 – None
2 – Extensor response to pain
1 – No response

=3 =4 =1 Limitations
of the
Glasgow
Coma Scale
Factors like drug use, alcohol intoxication , shock, or low blood oxygen can
alter a patient’s level of consciousness. These factors could lead to an
inaccurate score on the GCS.
 Eye opening Movement Verbal

 Obeys commands
4– 5 – Oriented
Spontaneous
3 – To speech 5 – Localizes to pain 4 – Confused
2 – To pain 4 – Withdraws from pain
3 – Inappropriate words

1 – None 2 – Incomprehensible sounds

3 – Abnormal flexion to pain
1 – None
2 – Extensor response to pain
1 – No response

=3 =4 =2

Eye opening Movement Verbal

 Obeys commands
4– 5 – Oriented
Spontaneous
3 – To speech 5 – Localizes to pain 4 – Confused
2 – To pain 4 – Withdraws from pain
3 – Inappropriate words
1 – None 2 – Incomprehensible sounds
3 – Abnormal flexion to pain
1 – None
2 – Extensor response to pain
1 – No response

=3 =4 =3

Eye opening Movement Verbal

 Obeys commands
4– 5 – Oriented
Spontaneous
3 – To speech 5 – Localizes to pain 4 – Confused
2 – To pain 4 – Withdraws from pain
3 – Inappropriate words

1 – None 2 – Incomprehensible sounds

3 – Abnormal flexion to pain
1 – None
2 – Extensor response to pain
1 – No response

=3 =4 =3